CC-SCHFI v2 (English)

Authored by

Ercole Vellone, PhD, RN

Associate Professor in Nursing Science

Department of Biomedicine and Prevention
University of Rome “Tor Vergata”,
Via Montpellier, 1 – 00133 Rome, Italy
Phone + 39 06 72596802 
Fax + 39 0672596961
Mobile + 393387491811
Skype: ercole.vellone
email: ercole.vellone@uniroma2.it

CAREGIVER CONTRIBUTIONS TO SELF-CARE OF HEART FAILURE INDEX v.2

All answers are confidential.

We kindly ask you to answer the following questions so that we know what you do for the person with heart failure. There are not right or wrong answers.

 

SECTION A:

 

How often do you recommend these things to the person you care for?

(Or, how often do you do these activities because the person you care for is not able to do them).

 

 

Never

 
Sometimes

 

Always

1.      Try to avoid getting sick (e.g., wash your hands)?

1

2

3

4

5

2.      Get some exercise (e.g., take a brisk walk, use the stairs)?

         1

2

3

4

5

3.      Eat a low salt diet?

1

2

3

4

5

4.      See the health care provider for routine health care?

1

2

3

4

5

5.      Take prescribed medicines without missing a dose?

1

2

3

4

5

6.      Order low salt items when eating out?

1

2

3

4

5

7.      Make sure to get a flu shot annually?

1

2

3

4

5

8.      Ask for low salt foods when visiting family and friends?

1

2

3

4

5

9.      Use a system or method to help remember to take medicines?

1

2

3

4

5

10. Ask your health care provider about medicines?

1

2

3

4

5

 

 

 

 

 

 

 

SECTION B:

Listed below are changes that people with heart failure commonly monitor. How often do you recommend to the person you care for to do the following things? Or, you do the following things because the person you care for is not able to do them.

 

 

Never

 
Sometimes

 

Always

11. Monitor weight daily?

1

2

3

4

5

12. Pay attention to changes in how he/she feels?

1

2

3

4

5

13. Look for medicine side-effects?

1

2

3

4

5

14. Notice whether he/she tires more than usual doing normal activities?

1

2

3

4

5

15. Ask the health care provider how he/she is doing?

1

2

3

4

5

16. Monitor closely for symptoms?

1

2

3

4

5

17. Check ankles for swelling?

1

2

3

4

5

18. Check for shortness of breath with activity such as bathing and dressing?

1

2

3

4

5

19. Keep a record of symptoms?

1

2

3

4

5

 
 
The last time the person you care for had symptoms…

(circle one number)

 

Has not had symptoms

I did not recognize the symptom

Not Quickly

 

Somewhat Quickly

 

Very Quickly

20. How quickly did you recognize that he/she had symptoms?

N/A

0

1

2

3

4

5

21. How quickly did you know that the symptom was due to heart failure?

N/A

0

1

2

3

4

5

 

 

 

 

 

 

 

 

SECTION C:

Listed below are behaviors that people with heart failure use to control their symptoms. When the person you care for has symptoms, how likely are you to recommend that he/she use one of these? Or, you do these because the person you care is not able to do them?

 

(circle one number for each treatment)

 

Not Likely

 

Somewhat Likely

 

Very Likely

22. Further limit the salt he/she eats that day?

1

2

3

4

5

23. Reduce fluid intake?

1

2

3

4

5

24. Take a medicine?

1

2

3

4

5

25. Call the health care provider for guidance?

1

2

3

4

5

26. Ask a family member or friend for advice?

1

2

3

4

5

27. Try to figure out why he/she has symptoms?

1

2

3

4

5

28.  Suggest that he/she limit activity until he/she feels better?

1

2

3

4

5

 

 

Think of what you did the last time the person you care for had symptoms… (circle one number)

 

 

I did not do anything

Not Sure

 

Somewhat Sure

 

Very Sure

29. Did the treatment you used make him/her feel better?

0

1

2

3

4

5